Incidents for Reflection:

One March evening, a tornado swept into the town of Greenville,
S.C. hurling trees, smashing homes and inflicting severe injuries.
Coloring the trees the next morning were not spring cherry blossoms but
pink insulation from the ravaged homes in this religiously conservative,
Protestant community. Representatives from the area Mental Health Center
interviewed residents who sought federal disaster relief to determine
whether any suffered Post Traumatic Stress Syndrome based on the symptom
criteria in the Diagnostic and Statistical Manual-III.

Of the 116 respondents, 69 people, or 59%, qualified for a
diagnosis of acute Post Traumatic Stress Syndrome, 19 of whom had a
severe form. Not one of these persons, however,
came to the area Mental Health Center for help. At a 15-month
follow-up 43% were still suffering from the disorder (Madakasira and
O'Brien, 1987).

A devoutly religious man entered therapy with a particular
psychiatrist who viewed religious commitment differently than his
patient. The psychiatrist denigrated his patient's long-standing
religious commitment, calling it "foolishly neurotic."

"Because of the intensity of the therapeutic relationship, the
interpretations caused great distress and appeared related to a
subsequent suicide attempt" ("Guidelines Regarding Possible Conflict
Between Psychiatrists' Religious Commitments and Psychiatric Practice,"
(1990), American Journal of Psychiatry, 147(4), 542).

What potential reasons might you suggest to explain why none of the
disaster victims sought help at the area Mental Health Center?

How does the second incident illustrate discrepant values concerning
religious commitment?

Objectives

At the conclusion of this module, you will be able to:

Compare rates of religious commitment in the general public to
rates among mental health professionals.

Describe the resistance among mental health professionals who
personally value religion but refrain from recognizing religious
commitment as a potential factor in therapy.

Identify four strategies for dealing with religious factors in
therapy.

Describe each of these positions, identify your personal approach
and explore alternative strategies.

Identifying Implications

Returning to the victims of the tornado in South Carolina, what reasons
might explain why none of those suffering from Post Traumatic Stress
Syndrome sought help at the area Mental Health Center?

When presenting his study of the disaster victims at an annual medical
meeting, the area Mental Health Center psychiatrist was at a loss to
explain why none of those surveyed who were suffering from Post
Traumatic Stress Syndrome sought help at the area Mental Health Center.
Based upon the research on those who seek help from mental health
professionals, another presenter responded that perhaps those people in
a religiously conservative Protestant community were reluctant to go to
the clinic out of concern for how their personal religious value system
might be treated.

A gap between how the majority of mental health professionals view
religion - as negative or unimportant - and how the general public's
view of religion -as positive and important - can create a barrier which
prevents those needing treatment from getting the psychological help
that they need.
Concerning the man berated for his religious beliefs who then attempted
suicide, what discrepancy exists between how the therapist and patient
each valued religious commitment?

This particular incident illustrates a "worse case scenario." It was
presented as an illustration in the American Psychiatric Association
ethics guidelines on religion and psychiatric practice which stated,
"Psychiatrists should maintain respect for their patients' beliefs" (APA
Board of Trustees 1990, p. 542).

FOOD FOR THOUGHT

Even when a mental health professional does not overtly criticize
religious convictions as negative or neurotic:

What are the implications of ignoring religious commitment in the
process of therapy?

What messages does a patient receive when a therapist appears
disinterested or declines to inquire further about religious convictions
when brought up by the patient?

Is there a disparity between how the majority of mental health
professionals view religious commitment and how the general population
views it? How can we objectively answer this question? What does the
research say?

Examining the Research

Approach

In order to assess the differences in levels of religious commitment
among mental health professionals and the general public, surveys of the
religious beliefs and practices of each group were compared. How did
they contrast?

Outcomes

For more than four decades, the Gallup Organization has conducted
scientific polling among Americans. Throughout this time period, the
proportion of Americans who believe in God has remained remakably
constant: 96 % in 1944 and 94% in 1986 (Princeton Religion Research
Center, 1993).

Also, 66% of the general public consider religion to be most
important or very important in their lives. Approximately 33%
of Americans view religious commitment as the most important
dimension of their lives. For another 33%, it is a very important
dimension. Furthermore, 72% agree or strongly agree with the
statement, "My religious faith is the most important influence in my
life" (Princeton Religion Research Center, 1994; Bergin and
Jensen, 1990).

Some 40% of Americans attended church or synagogue in the last week, a
figure which has remained relatively constant for more than 20 Gallup
surveys undertaken between 1939 and 1993 (Princeton Religion Research
Center, 1994).

Finally, what percentage of the general population considers religion
"not very important?" Some 12% (Princeton Religion Research Center,
1994).

Bergin and Jensen (1990) polled psychotherapists
nationally in order to determine the religious preferences of various
groups of mental health professionals.

They found that on average, mental health professionals have
somewhat higher rates of atheism and agnosticism than the general
population: approximately 16% vs. 6% (Gallup, 1989). Rates of
atheism and agnosticism among mental health professionals were combined
as follows:

Clinical Psychologists 28 %

Psychiatrists 21 %

Clinical Social Workers 9 %

Marriage and FamilyTherapists 7 %

Likewise, 80% of the mental health professionals surveyed expressed a
religious preference compared to 91% of the general population. For the
professionals, Protestant was the most common religious preference
(38%). However, the next largest group was atheist, agnostic, humanist
or none (20%).

On the other hand, Bergin and Jensen found that while "the
professionals' rates of conventional religious preferences were lower in
some respects than the public at large", there was, nonetheless, "an
unexpected, sizeable personal investment in religion." For example,
77% of the professionals agreed with the statement, "I try hard
to live by my religious beliefs." In comparison, on a similar
Gallup survey item, "I try hard to put my religious beliefs into
practice in my relations with all people...," some 84% of the general
public agreed.

Furthermore, 41% of the mental health professionals indicated
that they attend religious services on a regular basis. A rate that is
virtually the same as that found for the general population.

In their survey, Bergin and Jensen asked respondents to agree or
disagree with the statement, "My whole approach to life is based
on my religion." Mental health professionals who agreed or
strongly agreed were as follows:

Clinical Psychologists 33 %

Psychiatrists 39 %

Clinical Social Workers 46 %

Marriage and Family Therapists 62 %

Bergin and Jensen, as noted above, refer to a similar Gallup survey
item, "My religious faith is the most important influence in my
life." 72% of the general public agreed or strongly agreed
with this statement. A comparison of these figures suggests that there
may be significant differences in the extent to which members of the
general population and mental health professionals - particularly
clinical psychology and psychiatry - endorse a religious view of life.

FOOD FOR THOUGHT

What do you think the implications of this religious commitment gap are
in addressing religious issues in therapy?

Since 72% of the general public claim to be influenced significantly by
their religious faith, religious commitment may be an important factor
to draw upon in therapy.

By excluding religious commitment issues from the
therapeutic setting, there remains a denial of an aspect of life which
has shown to be of central importance to nearly two thirds of the U.S.
population.

The general public appears to view and value religion as a central
factor in their lives, whereas many mental health professionals do not.
There is a gap in how each values religion, which may potentially lead
to harmful misinterpretation and mishandling of religious issues in the
therapeutic setting.

In addition, some therapists who value religion in their personal lives
may set aside their personal perception and refrain from inviting the
patient to deal with religious commitment in therapy.

Do they keep that doorway shut, closing off the opportunity of
addressing a potentially significant factor for the patient?

Examining the Research

APPROACH

Two surveys were compared to determine whether there is an open
or closed door between how therapists value religion in their own lives
and the way they perceive the role of religious commitment in the lives
and mental health of their patients.

OUTCOMES

In a 1990 survey of Mental Health Professionals, Bergin and Jensen found
that although nearly half did not base their whole approach to life on
their religion, some 77% agreed with the statement, "I try hard to live
by my religious beliefs."

The authors then compared this figure with a survey of what factors
therapists believed were important to mental health. Surprisingly, only
29% of therapists rated religious content as important in treatment with
all or many clients or patients (Jensen and Bergin, 1988).

FOOD FOR THOUGHT

Do you think religiously committed therapists should open this doorway
or keep it closed? What do you think would be the consequences of
opening the doorway and addressing religious issues in therapy?

What undercurrent of pressure within the mental health profession might
contribute to the suppression of religious issues in therapy?

A majority of psychotherapists - even those who personally value
religion - often fail to recognize the potential significance of dealing
with religious commitment in therapy. Does this failure have an impact
on who religiously committed patients might turn to for help with
psychological problems?

Examining the Research

APPROACH

In order to examine whether people with mental health disorders
sought help from mental health professionals, clergy or both, data from
a national study was analyzed.

Data for the analyses came from the Epidemiological Catchment Area (ECA)
Survey which sought information on demographics, health and mental
health services utilization, and psychiatric diagnosis among a sample of
adults at five sites.

Psychiatric status was determined by interviewing people in the
communities with the Diagnostic Interview Schedule, a research
instrument used to assess psychiatric disorders. The five sites
were New Haven, Conn.; eastern Baltimore, MD.; St. Louis, Mo.; five
counties in the Durham, NC area; and the Venice and East Los Angeles
areas of Los Angeles County, CA.

OUTCOMES

The analysis focused on people with psychiatric symptoms who
had sought help for problems with emotions, nerves, drugs, alcohol or
mental health at any time in their lives.

Perhaps the most striking finding was that in a similar manner across
the five sites, persons with serious psychiatric disorders were just as
likely to seek hlep from clergy as they were to seek help from mental
health professionals.

Those seeking help from the clergy were just as likely to have
major psychiatric disorders as those seeking help from mental health
professionals. Sometimes, those with severe disorders such as
major depression, schizophrenia and bi-polar disorder sought help from
both. However, some with severe disorders only sought help from the
clergy.

Exceptions were individuals with a history of alcohol or drug abuse who
preferred to seek help from mental health specialists rather than
clergy. Persons with those disorders tend to be non-religious (McDonald
and Luckett, 1983).

The data showed that clergy - with or without the help of mental health
professionals - were coping with a broad spectrum of psychiatric
disorders which they may or may not have been prepared to handle
(Larson, et. al., 1988).

FOOD FOR THOUGHT

What are the implications of the fact that persons with severe mental
health disorders may choose to seek help from a member of the clergy
rather than a mental health professional?

What could be done to educate and assist members of the clergy who might
be hesitant to recommend a mental health professional for a
parishioner?

Some persons with serious mental health disorders only seek help from
the clergy. How might they be encouraged to also seek professional
psychological help which may be needed as well? Who might help bridge
the gap - or open the doorway?

Examining the Research

APPROACH

A survey was undertaken to find out how mental health
professionals who personally value religion choose to integrate a
patient's religious commitment into therapy?

OUTCOMES

According to survey results published in the American
Journal of Psychiatry, a growing number of religious psychiatrists
actively promote new approaches to psychotherapy based on conventional
religious commitment (Galanter, Larson and Rubenstone, 1991).

The survey, which polled psychiatrists who were members of the Christian
Medical and Dental Society, found that these psychiatrists believed that
prayer and the Bible could be used effectively to help patients deal
with grief reactions, suicidal intent, sociopathy and alcoholism
However, acute manic episodes or acute schizophrenic episodes were
believed to be best dealt with by psychotropic medication.

The results showed the average Christian psychiatrist to be a prominent
member of his profession: 59% held faculty appointments at a medical
school, 68% were board certified and 88% were members of the American
Psychiatric Association.

These religious psychiatrists have integrated aspects of conventional
religious commitment into therapy with religiously committed patients.
Is it only possible for therapists who personally value religion to
bridge the gap and use religious content in therapy?

Examining the Research

APPROACH

A carefully controlled study was designed to examine whether using
religious content in therapy - conducted by either religious therapists
or non religious therapists - would be more or less effective in the
treatment depressed patients.

OUTCOMES

A study of clinically depressed patients compared the
effectiveness of treatment when using a cognitive behavioral therapy
either with religious content or without. Religious and non-religious
therapists were used in each treatment.

Depressed patients receiving treatment involving religious
content did better than patients with whom religious content was
omitted. This was determined by using the measures of post-
treatment depression and adjustment scores on standardized tests. Of
note was the fact that the non-religious therapists, using
the religious approach, had the highest level of treatment effect
(Propst, 1992).

Acrossthe Gap: Therapists who
personally do not value religious commitment and ignore it or primarily
see it as harmful for their patients.

The Collaborative: Therapists who personally are
not religiously committed but respect and deal positively with religious
commitment in therapy.

Behind the Door: Therapists who personally hold
religious values but ignore or refrain from dealing with religious
commitment and religious values in therapy.

The Conjoint: Therapists who personally are
religiously committed and who deal with religious commitment in therapy.

Please see figure on the following page.

Identifying Implications

Where are you presently on this matrix?

What steps across the "Gap" can mental health professionals take
to become "Collaborative" and sensitive to their patients' religious
commitment? Or how might they pave avenues to refer patients to a
"conjoint" therapist if they feel uncomfortable dealing with religious
issues?

What steps can a mental health professional behind the "Door" take
to become "Conjoint?"

Our education has made us increasingly sensitive to prejudice against
race, gender, ethnic groups and socio-economic levels. However, how
sensitive have we become to respecting religious commitment and the
role it plays in the lives of the majority of our patients?

For the more than 70% of the population for whom religious commitment is
a central factor, "secular approaches to psychotherapy may provide an
alien values framework," state Bergin and Jensen. They continue:

A majority of the population probably
prefer an orientation to counseling and psychotherapy that
is sympathetic, or at least sensititve, to a spiritual
perspective. We need to better perceive and respond to this
public need (Bergin and Jensen, 1990).

FOOD FOR THOUGHT

Would you agree or disagree with Bergin and Jensen's statement? What do
you think might contribute to therapists, at times, failing to take into
account the religious dimension of a patient's life?

Directions: There are seven questions presented to
reinforce your knowledge of the preceding information. In Part A,
please fill in the blanks with the correct answer. Then, in Part B,
match the term with the appropriate definition.

Part A

A series of Gallup polls have determined that %
of the U.S. population believe in God, while a much lower % of the U.S. population does not consider religion to be very
important.

_____ % of the general public endorsed the statement
in a Gallup survey, "My religious faith is the most important influence
in my life." In contrast, responses for mental health professionals to
the statement, "My whole approach to life is based upon my religion"
included a low of ______ % for clinical psychologists and a high
of _____% for marriage and family therapists.

In one of the reviewed surveys, non-religious persons were those
who called themselves: atheist, agnostic, humanist or had no belief.
The range for mental health professionals who fall into this category
went from a low of 7% for clinical social workers to a high of 28% for
_____________ .

Part B

TERMS

4. Across the Gap

5. Behind the Door

6. The Conjoint

7. The Collaborative

DEFINITIONS

a) Therapists who personally are not religiously committed but
respect and deal positively with religious commitment in therapy.

b) Therapists who personally hold religious values but ignore or refrain
from dealing with a patient's religious commitment as a component in
therapy.

c) Therapists who personally do not value religious commitment and
ignore it or see it as harmful to their patients.

d) Therapists who personally are religiously committed and who deal with
religious commitment in therapy.